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Dysautonomia and PCS

Dysautonomia – A possible cause of post-concussion syndrome

Dysautonomia and PCS

With concussion being a dominant topic in sports medicine, we have seen a large spike in research dollars being spent to study the effects of brain injury. Despite our increased knowledge, when someone has concussion symptoms for longer than 30 days, there still isn’t great consensus as to why these people develop persistent symptoms and what is causing it to happen.

The symptoms of post-concussion syndrome (PCS) are what make the illness difficult to understand. The primary symptoms of PCS include:

  • Persistent headache
  • Dizziness
  • Loss of balance
  • Difficulty with concentration/brain fog
  • Nausea
  • Impaired or slow cognitive activity

The symptoms are vague and non-specific. In medicine, there’s a tendency and a desire to have a condition be linked to one very specific piece of anatomy. That way you can treat the diseased organ and cure the illness.

The reality is that a head injury is likely disrupting multiple body parts simultaneously. The higher centers of the brain aren’t the only things that get scrambled during a concussion. A concussion is likely damaging multiple areas in the brain along with the inner ear organs, the neck, the jaw, and the eyes.

Since every head injury is unique in terms of velocity, direction, and magnitude, it means that each person’s head injury is likely to impact their anatomy in individual ways. This is where you can have a lot of variation in how someone with post-concussion syndrome looks symptomatically.

Another struggle is that different body parts can create similar symptoms. An injury to the neck can cause a feeling of vertigo just like an injury to an inner ear organ. An injury to the neck can also cause headaches symptoms just like the eyes or the vessels in the brain.

Some doctors are looking at another potential cause of persistent concussive symptoms called dysautonomia.

Dysautonomia – A Fight Between 2 Super Systems

Dysautonomia is a condition where the brain loses normal control of the internal organ systems of your body. Dysautonomia can show up in organs like the digestive system, bladder, glands, and pupils. Classically, these disorders show up in the cardiovascular system by affecting your heart rate and blood pressure.

Autonomic Nerveous System Chart

The autonomic nervous system is compromised in patients with dysautonomia

The most common disorders linked to dysautonomia are:

  • Multiple sclerosis
  • Fibromyalgia
  • Postural Orthostatic Tachycardia Syndrome (POTS) – an illness characterized by rapid heart beat to 150-200 bpm at rest
  • Neurocardiogenic syncope – a disorder characterized by unpredictable fainting attacks.

When people have these disorders then the broken function of the nervous system causes people to feel dizzy, in a fog, extremely fatigued, light headed, and anxious. When you read those symptoms on paper (or screen) it doesn’t sound like much, but the way those symptoms persist can drive someone mad.

People don’t just have a brain fog, they are scared and frustrated that their brain won’t allow them to focus and accomplish a task.

People don’t just have fatigue, they have an inability to socialize and be effective at work and at home because of exhaustion.

People don’t just have dizziness, they are worried about driving and being in open spaces because their body is betraying them.

People don’t just have a rapid heart beat, they have fear and anxiety that this next attack could put them in the emergency room.

Having dysautonomia whether it’s an illness on it’s own like POTS, or part of another illness like MS can make life much harder and depressing, because treatment for the illness is really limited.

Post-Concussion Syndrome and Dysautonomia

Going back to post-concussion syndrome, we discussed how the illness can be extremely frustrating because doctors and scientists have had a hard time coming to a consensus as to where the symptoms are coming from.

Some doctors and scientists are presenting an interesting theory that cases of post-concussion syndrome may be a manifestation of dysautonomia.

One of the first studies to look at this phenomenon was done in 2016 on young patients with persistent concussion symptoms. The study involved a test called the head-upright table tilt test. You can check out the full study here:

Orthostatic intolerance and autonomic dysfunction in youth with persistent postconcussive symptoms: a head-upright table tilt study

Image credit to Stickman Communications

Image credit to Stickman Communications

This test is used to diagnose feinting conditions but is also a hallmark test for POTS. The study showed that 24 out of 34 PCS patients had findings on the test indicating a form of dysautonomia. 10 Patients had syncope while 14 patients had POTS.

Even more interesting was that when the patients with POTS stopped having PCS symptoms, they also stopped having a reaction to the table tilt test when re-examined.

Another 2016 study showed that patients who have a history of concussion show a decreased ability to modulate their heart rate and blood pressure at rest indicating a loss of autonomic control. This was happening in patients without any overt signs or symptoms of dysautonomia.

Valsalva maneuver unveils central baroreflex dysfunction with altered blood pressure control in persons with a history of mild traumatic brain injury

Then you also have a wide range of studies looking at how concussion can impact your heart rate variability which is an increasingly utilized biomarker for autonomic nervous system activity.

HRV Studies

A dysautonomic theory of post-concussion syndrome can also help explain some of the unusual symptoms that may arise after a head injury. While it’s easy to understand how a PCS patient can have persistent headache and dizziness, there are a lot of people who will have a concussion or whiplash and start developing persistent gut issues and sensitivities to foods. Dysautonomia as a culprit helps to make better sense of this phenomenon.

What Does This Mean for Treatment?

Dysautonomia is a condition that is not well recognized by many physicians and there aren’t many choices for effective treatment options. In dysautonomia, the brain is having a terribly hard time making sense of its environment.

There’s some interesting work going on utilizing balance and vestibular exercises and graded cardiovascular exercise to help the brain recover from injury, but I’ll cover that on another day. Today I want to talk about the veins in your neck.

Dr. Michael Arata is an interventional radiology specialist in Southern California. I heard him speak at a conference in 2015 where he talked about the effect that the veins in your neck could have on your autonomic nervous system. It’s been an interesting and controversial theory that has been tied to illnesses like multiple sclerosis where dysautonomia is a hallmark of the illness. When the large veins in the neck become narrowed or occluded, it can cause abnormal fluid movement in the brain leading to venous reflux, congestion, and neuroinflammation in the brain.

Dr. Arata even published 2 studies that demonstrating that a procedure that uses a balloon to open these veins was able to create changes in the autonomic function of patients with multiple sclerosis including heart rate variability and blood pressure control.

Transvascular autonomic modulation: a modified balloon angioplasty technique for the treatment of autonomic dysfunction in multiple sclerosis patients.

Blood pressure normalization post-jugular venous balloon angioplasty

But that wasn’t the most interesting part of his presentation. During his talk, he talked about the concept of the atlas vertebra creating compression on these vascular structures. He even used an imaging technique called a venogram to show this happening in his patients:

Dr. Arata shows images of a venagram to show how atlas rotation can disrupt the internal jugular vein

Dr. Arata shows images of a venagram to show how atlas rotation can disrupt the internal jugular vein

It’s because of this phenomenon that Dr. Arata actually refers some of his patients for upper cervical correction so that they can influence this part of the autonomic nervous system.

If dysautonomia is a primary symptom generator in PCS patients, then the impact from a potential neurovascular insult like an craniocervical displacement should be considered especially considering the mechanism of injury includes a blunt force to the head.

An Personalized Approach to Post-Concussion Syndrome

Patients with post-concussion syndrome with signs of dysautonomia likely have multiple systems that must be addressed to regain normal functionality. In addition to dysfunction in multiple systems is the idea that each person will have a varying tolerance to different therapies.

In truth, no single therapy is likely to fix someone with persistent post-concussive symptoms and dysautonomia. These patients need to improve their tolerance to exercise with gradual increased load (especially if they’re an athlete). They also need vestibular rehabilitation so that their brain can move the head and eyes normally again. There’s no disputing the necessity and usefulness of those treatment strategies.

However, if we are concerned about the chronic effects of head injury and the ability to improve fluid movement through the brain, then we have to consider the impact that trauma has on the structural alignment of the neck and the neuroinflammatory consequences that these injuries can leave behind.

Send Dr. Chung a Question

 

 

TMJ and the Atlas

Research: Atlas Correction and TMJ Pain

TMJ and the Atlas

Read Time: [5 min]

Last month a study produced by the Upper Cervical Research Foundation was published that examined the effect that Atlas Corrections had on the function of the temporomandibular joint. It’s a first step towards solidifying our understanding on how the work we do in our office can be a powerful help to patients suffering from chronic jaw pian/TMJD.

The Study

Relationship between craniocervical orientation and center of force of occulsion in adults

The authors of the study are clinicians in active practice. They took 11 chiropractic patients who were presenting for regular check ups and showed signs of Atlas Displacement Complex. The patients were sent to a neuromuscular dentist to evaluate their bite patterns before and after performing an Atlas Correction. The bite evaluations were performed with a digital force analysis that is able to show unequal force on different parts of the bite.

This unequal force is known in dentistry as dental occlusion. The goal is to allow for equal distribution of the force from your bite throughout the teeth and jaw, which can help people with TMJ pain by decreasing abnormal tension in the jaw muscles.

The patients were tested 2 times before an adjustment and 2 times after an adjustment.

Results

Postural measurements were taken before and after the adjustment. As expected, patients experienced significant changes in their postural measurements after their adjustment.

With the jaw measurements…there’s good news and not so great news. The good news is that for most of the cases, there was a measurable and significant change in force and pressure coming from the jaw.

Force profiles of the teeth and jaw before and after Atlas Correction

Force profiles of the teeth and jaw before and after Atlas Correction

The not so good news is that the change didn’t necessarily lead to an evenly distributed force pattern, meaning that the change may or may not have been positive.

Important Points

  • Small sample size
  • The patients were used as their own control as opposed to having a control group
  • The patients were active chiropractic patients with no history of TMJ issues. We can’t say for sure if this effect is beneficial for patients with jaw pain.
  • The patients tested were current patients with a history of chiropractic care. Would the results look different using new chiropractic patients who have never had an atlas correction before?

 

What now?

While no definitive conclusions can be made about the benefits of correcting the neck, we now have some data that shows that affecting the neck can and does affect the function of the jaw.

Our experience working with hundreds of TMJ cases, as well as the experience of hundreds of doctors around the country suggest that correcting the neck can have a very powerful affect on cases of jaw pain and even popping and clicking.

Time will tell and with better studies how effective NUCCA can be for this debilitating pain condition.

 

Post-Concussion Syndrome

Case Study: 6 months of Post-Concussion Syndrome

Post-Concussion Syndrome

 

Read Time: [3 minutes]

Post-concussion syndrome has become a big deal with more athletes showing concern about the risks of chronic brain injury. Recovery from a concussion usually takes about 7-10 days for most people but many will have symptoms that last 30 days or more.

Our most recent case had post-concussion syndrome that lasted 6 months prior to visiting our office.

Background

A young woman was a passenger in a car that was struck from the side. The shock of the accident caused her head to whip from side to side and she lost consciousness immediately.

Although many concussions are a result of a direct blow to the head, a concussion can occur through rapid acceleration and deceleration of the head causing the brain to move and collide with the inside of the skull.

Following the concussion, the patient began having daily episodes of migraine headaches. During the migraine attacks, she would also have vertigo that led to a persistent feeling of nausea.

After being discharged from the hospital the patient was seen by an orthopedist and chiropractor. While chiropractic adjustments were helpful, she felt her symptoms come back repeatedly within hours of her treatment. The patient had an appointment with her orthopedist to receive neck injections, but was referred to our office before that to see if correcting her atlas would help.

Assessing the Neck in Concussion

The patient was put through a full examination to evaluate the  neck. In many cases of post-concussion syndrome, the neck has numerous pain-generating tissue that can be responsible for these neurological symptoms. This includes precise x-rays of the top of the neck, evaluation of neck muscle tone, structural positioning, and evaluation of head and neck control.

You can see some images of our head control laser testing below.

img_4266

Laser head positioning system

Testing head control using a maze

Testing head control using a maze

When people suffer a concussion or whiplash injury, it can cause damage to the muscles and allow us to control our head and neck movement. These injuries can lead to headaches, but they also cause problems with our sense of balance.

Once we have some baseline information on their current abilities, we can monitor how they respond and heal from the damage to their neck.

Results:

After her 2nd visit, the patient said that her headaches and nausea were almost completely non-existent.

Imagine that. Going from daily migraines, to no headaches for an entire week. All from a getting the head and neck into a better structural position.

Now that isn’t to say that life is perfect after that. There were certainly some ups and downs along the way. Overall, the patient’s headaches have improved about 80% in frequency and intensity. She has elected to skip getting injections, and is working hard everyday to get stronger.

Here’s the most important element and really the part that matters:

After the head injury, the patient was unable to do the things that made her life fun. She had trouble working out and getting motivated to exercise. Staying focused at work meant having to rely on pain killers. Taking care of a young daughter meant gritting her teeth through pain and nausea instead of being present in the moment.

That’s what all of this is about. It’s not about the pain reduction, it’s about the restoration of normal life!

For more information, you can read this patient’s testimonial below:

I’m a very active mommy that carries around the weight of a 6 year old and owning a salon full time. Work and mommy duties call for my body to be at all times ready and with it. There isn’t time for rest, much less any fatigue or achy-ness. Between playing sports when I was young, actively working out and having the burden of standing on my feet the majority of my work days, my simple adjustments just got me through. I didn’t realize that there could be a cure for my migraines, constant neck stiffness and what seemed to be a much older body that I was trapped in.

I was a back seat passenger in a car crash on New Years, where the car was deemed totaled. There were no major signs of trauma, besides the concussion and black eye I received, however, I knew something was wrong when my pain was continuing to get worse months after the accident. My routine visits to the chiropractor, became tedious weekly visits that just got me through; my pain kept coming back if I didn’t get adjusted that day. I refused to succumb to cortisone shots previously, but felt desperate. Instead of my Chiropractor sending me off the receive the possible relief from an invasive procedure, he referred me to his dear friend Dr. Chung that specializes in post concussion, migraines, fatigue and achy-ness.

Dr Chung was very thorough and did a series of X-rays and tests to see how my whole body was aligned and reviewed my MRI. He explained the symptoms and showed me what was happening to my brain and surrounding inflamed tissues. After one precise adjustment and many months of not being able to be active or myself, I felt 150%. I was scared and apprehensive as to when my pain would return. To my surprise, months later and just a few maintenance NUCCA adjustments, my pain has not returned and I was immediately able to carry on with my workouts, mommy life and my physically involved career. I was even able to hike, travel and do Cross-fit within weeks of being adjusted. My energy and range of motion has returned. I couldn’t be happier for the referral to such a dedicated, intelligent, passionate Doctor of Chiropractic. Thank you so much for your passion to treat your patients and wish you much success.
Jessica S.

Head tilt

Why Does My Head Always Tilt to the Side?

Head tilt

Read Time: [5-7 minutes]

How do I know if someone has an Atlas problem? Can a regular person see it?

Head tilting posture is something we’re used to seeing with curious puppies, but it may be a sign of a problem in the central nervous system. This can be one of the most important signs of poor neurological activity even in the absence of pain or symptoms.

Head tilt

Image from paper in the journal Laterality. Source: http://www3.canisius.edu/~noonan/research/researchreports/human_head_tilt.htm

Poor Head Position = Poor Interpretation of Gravity

Poor head positioning is one of the most important postural findings I look for in a Structural Chiropractic Examination. From a clinical perspective, it’s a lot more important than something like slouching. For the most part, people have the ability to recognize and correct a slouching posture when they want to. When it comes to a persistent head tilt, most people have no idea when it’s happening. It’s also a posture that is related to things like head injury, whiplash, or a balance problem.

When you have a persistent head tilt, you typically don’t know that your head is tilting because in your mind, it’s perfectly straight. This is an underlying indicator that your brain is working inefficienctly.

When you really think about it, posture is primarily your brain’s response to gravity. Whatever your body experesses as a straight posture is how your brain thinks it needs to exist in a gravitational environment. That means that a crooked head position means that the brain is getting bad input, which is leading to poor output.

Garbage in, garbage out

What does garbage out look like to the body? Garbage out expresses itself as Secondary Conditions like:

  • Headaches
  • Facial pain
  • TMJ
  • Vertigo
  • Balance Problems
  • Syncope (Dysautonomia)

All common problems experienced after a concussion or whiplash injury.

Why Head Tilt?

So what does head tilt have to do with concussion, whiplash, and all of these Secondary Conditions?

When your head and neck is exposed to a force, it can affect one of 3 systems in the body that control and regulate your balance and posture.

  1. Visual and Ocular system
  2. Inner ear/vestibular system
  3. Neck/Spine Proprioceptive system

Together these 3 systems integrate into your brain so that your brain knows how to regulate your body in space.

Your vision and movement of your eyes make sure that your head stays level. Your ears tell your brain if your head is moving. Your joints provide information on if your limbs or your spine are moving.

This system works best when all 3 give the same information. If your eyes and muscles say one thing, but your ears say another, then it creates a problem for the brain to process.

The 3 systems that form the Balance Triad

The 3 systems that form the Balance Triad

When you take a blow to the head or neck, then these structures can become damaged and start to malfunction.  We can see this malfunction manifest as a persistent head tilt to the side.

Head tilt may not be the cause of these problems, but it is a clear and obvious sign of a breakdown in this system.

It’s easy to see how a blow to the head can affect the neck because the two structures are connected via the top bone in your neck called the Atlas. In our Wellington office, we handle this problem by re-centering the head on top of the neck again utilizing the NUCCA procedure.

When the head is centered, then it’s almost like a re-boot to the system to make the brain work normally again.

Not All Head Tilts Cause Pain

Notice that not all head tilts cause pain, but head tilt is almost always a sign of a problem in the brain. Lots of people can go through a bad car wreck and not feel any pain immediately. However, the structure of their spine and the function of the brain has changed. This means that a problem can develop over time due to chronic malfunction of the nervous system.

That’s why everyone should get checked for a Atlas Displacement after an injury even if there’s no pain or symptoms present.

Not All Head Tilts Are a Neck Problem

Not every head tilt is related to a problem in the neck, though there is almost always at least some contribution from the neck. As we discussed earlier, there are 3 main systems that dictate your sense of balance.

There are times when I have done my best effort in correcting someone’s neck that a head tilt persists. That’s why it’s important to work with a team of professionals that are capable of addressing this problem.

  • Optometrists/Vision Therapy/Neuro-opthamology – These professionals are trained in addressing the ocular system. It’s a rapidly growing field thanks to our growing knowledge of concussion and how it affects the eyes.
  • Vestibular Therapist / Functional Neurologist – Special types of chiropractors and physical therapists are trained at rehabilitating problems in the inner ear. They use special assessments and exercises to restore normal function of the inner ear.

Remember: No one therapy cures all. An interdisciplinary approach is often the best way to solve many of these complex cases.

 

 

Anatomy

The Anatomy of a Headache

Anatomy

 

Outline: [5-10 minute read time]

  • Headaches come in different shapes and sizes and may have different anatomical triggers
  • The brain cannot generate pain. Head pain must come from a source outside the brain
  • Common sources of head pain
  • How head and neck positioning can help

Not all headaches are created equal. Part of being a doctor that sees patients of all shapes and sizes, we have to become familiar with the different types. Here’s a short list of the most common types:

  • Tension headache
  • Migraine headache
  • Sinus headache
  • Hypertensive headache
  • Cluster headache
  • Post-traumatic headache
  • Cervicogenic headache

It can be a challenge for a doctor to identify the type of headache you have because while these headaches have distinct characteristics, most of them overlap and make the clinical picture very gray. In some part, the type of headache you are having is determined by the anatomy that is generating the pain signal.

Although the pain of a headache can make it feel like your brain is going to explode,  there are actually zero pain generating tissues within the brain itself. That means that something outside of the brain is transmitting a signal to the brain that something has gone wrong. I won’t go into some some of the more serious secondary causes of headache like tumors, strokes, etc, this will be more focused on primary headache.

Headache Anatomy

1. Arteries in the brain -

For decades, scientists have studied arteries in the brain and their role in headaches. While we don’t know everything about migraines, we do know that migraine attacks tend to happen when the arteries of the brain swell and lead to inflammation of the nerves that are connected to the artery. These nerve endings are transmitted to the trigeminal ganglion causing the pain portion of the headache.

It’s for this reason that many of the drugs used to treat migraine are those that reduce the swelling of brain arteries. In fact, the target of new drug therapies are using antibodies to target the molecules that cause the arteries to open, and hopefully prevent the attacks from occurring to begin with.

2. C1, C2, C3 Nerve Roots

The top 3 nerves in your spine are highly linked to headaches following a head and neck injury. When someone suffers a whiplash injury or concussion, these upper cervical nerves can become irritated and generate pain across the back and top of the head. In some cases, this leads to a condition called occipital neuralgia where the nerves are chronically disturbed leading to unrelenting pain or numbness in the skull.

c1 c2 c3 nerves

The nerves coming from the top of the neck

 

3. The Meninges

The meninges is a layer of tissue that wraps around the brain, spinal cord, and nerves. When you hear people talking about meningitis, we are referring to this outer covering becoming enflamed. One of the symptoms of meningitis can be a bad headache, and the meninges can be a cause of headache pain even without a meningitis infection.

Some anatomical studies show that small muscles in the neck can connect into the meninges which may be the problem with certain types of headaches.

Brain Meninges

A cross-section of the skull showing the brain and the meninges

4. Head and Neck Muscles

Muscles of the head and neck have been long associated with tension type headaches. While the influence of these muscles in headache were exaggerated over the years, certain muscles do play a role in head pain. Neck pain generated by muscles like the  splenius capitus can generate pain that refers into the head.

With TMJ patients, the jaw muscles like the masseter, pterygoids, and temporalis muscles can become highly contracted and become potent pain generators which is one of the reasons why jaw problems are highly associated with headache.

Neck Muscles

Muscles commonly associated with headache

5. Dysfunctional Neck Joints

The joints of the neck play a large role in postural feedback to the brain. These joints are also sensitive to irritation through injury and chronic malpositioning. Headaches resulting from dysfunctional neck joints are known as cervicogenic headache. These types of headaches are hard to diagnose because they are generally classified by whether a neck treatment helps, but we do know that this is more commonly seen with whiplash and head injuries.

What Do They All Have In Common?

So here’s the fun part. What is it about all of these different pieces of anatomy have in common besides the fact that they all cause headaches? Neurologically it comes down to a bundle of nerves that make up the trigeminal complex.

The Trigeminal Complex

The Trigeminal Complex

This particular piece of anatomy is important because it is the hub for almost all pain signals in the head and neck. Everything from the C1-C3 spinal nerves, meninges, jaw muscles, and skin of the face gets transmitted and processed by these nerves. In some cases, a chronic headache problem might possibly be a less severe form of trigeminal neuralgia.

That means if we can can change the way the trigeminal complex is working, then we can have a meaningful effect on the status of someone’s headache disorder.

How Structural Correction of the Neck Can Help

In our Wellington office, we work heavily on correcting the positioning of the top part of the neck. We talked about how C1, C2, and C3 nerves can transmit pain in regards to a headache, but they also transmit valuable information about your posture and positioning in space.

When the head and neck are in a normal position, then this information gets to the brain without a problem and all seems well. However, a structural shift like Atlas Displacement Complex creates a scrambled signal into the brain and allows pain to be the dominant message. That’s why those nerves at the top of your neck are so important. They can dampen pain signals going into the trigeminal complex and stop the headache process from starting!

 

Image credit to Dan Murphy, DC thechiropracticimpactreport.com

Diagram showing how the nerves from the neck meet with the trigeminal nerves Image credit to Dan Murphy, DC thechiropracticimpactreport.com

 

Our success rate with headaches is so high, not because we’re treating each headache we see differently, but we are finding the neurological element that seems to tie them all together. In many cases, it can be as simple as the Atlas Displacement Complex.

 

 

Could your problems be the result of ADC?

Could your problems be the result of ADC?